Citation Nr: 21004085 Decision Date: 01/26/21 Archive Date: 01/26/21 DOCKET NO. 17-41 660 DATE: January 26, 2021 ORDER A 20 percent rating for lumbar and thoracic spine strain is granted from September 14, 2019. An initial rating higher than 10 percent before September 14, 2019, and a rating higher than 20 percent from September 14, 2019, for lumbar and thoracic spine strain is denied. An initial rating higher than 10 percent for right knee patellofemoral pain syndrome is denied. An initial rating higher than 10 percent for left knee patellofemoral pain syndrome is denied. A total disability rating due to individual unemployability is granted from July 25, 2015. REMANDED Entitlement to an initial rating higher than 10 percent for right ankle strain is remanded. Entitlement to an initial rating higher than 10 percent for left ankle strain is remanded. FINDINGS OF FACT 1. Resolving any reasonable doubt in the Veteran’s favor, the evidence is sufficient to show that from September 14, 2019, the Veteran’s lumbar and thoracic spine strain manifested in forward flexion of the thoracolumbar spine limited to 45 degrees during flare-ups and with repeated use over time. 2. For the period before September 14, 2019, the evidence is insufficient to support that the Veteran’s lumbar and thoracic spine strain manifested in forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; in combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, in muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour. 3. For the period from September 14, 2019, the evidence is insufficient to support that the Veteran’s lumbar and thoracic spine strain manifested in forward flexion of the thoracolumbar spine 30 degrees or less; or, in favorable ankylosis of the entire thoracolumbar spine. 4. The evidence is insufficient to support that the Veteran’s right knee patellofemoral pain syndrome has manifested in limitation of motion of the right leg to 45 degrees flexion or to 10 degrees extension; in dislocated semilunar cartilage with frequent episodes of effusion into the joint; or, in recurrent subluxation or lateral instability. 5. The evidence is insufficient to support that the Veteran’s left knee patellofemoral pain syndrome has manifested in limitation of motion of the left leg to 45 degrees flexion or to 10 degrees extension; in dislocated semilunar cartilage with frequent episodes of effusion into the joint; or, in recurrent subluxation or lateral instability. 6. From July 25, 2015, the Veteran had two or more service-connected disabilities, one rated at 40 percent or more, and which combined to 70 percent or more. 7. Resolving any reasonable doubt in the Veteran’s favor, the evidence from July 25, 2015, establishes that the Veteran’s combined service-connected disabilities have rendered him unable to secure or maintain substantially gainful employment due to his service-connected disabilities. CONCLUSIONS OF LAW 1. The criteria for a 20-percent rating for thoracolumbar spine strain have been met from September 14, 2019. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 4.3, 4.71a, Diagnostic Code 5237. 2. The criteria for an initial rating higher than 10 percent before September 14, 2019, and for a rating higher than 20 percent from September 14, 2019, for thoracolumbar spine strain have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.46, 4.71a, Diagnostic Code 5237. 3. The criteria for an initial rating higher than 10 percent for right knee patellofemoral pain syndrome have not been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.71a, Diagnostic Codes 5257, 5258, 5260, 5261. 4. The criteria for an initial rating higher than 10 percent for left knee patellofemoral pain syndrome have not been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.71a, Diagnostic Codes 5257, 5258, 5260, 5261. 5. The criteria for entitlement to a TDIU from July 25, 2015, have been met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 3.340, 3.400, 4.3, 4.15, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from July 2011 to July 2015. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a December 2015 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). In July 2020 the Board remanded the matter for adequate VA examinations and to obtain outstanding medical treatment records. As the directives of the July 2020 Board decision have been substantially complied with, the Board will now adjudicate the claims on the merits. Dyment v. West, 13 Vet. App. 141, 146–47 (1999); Stegall v. West, 11 Vet. App. 268, 271 (1998). A. Initial Ratings The Veteran appeals for higher initial ratings for service-connected disabilities of the thoracolumbar spine, bilateral knees, and bilateral ankles. The claims for the ankles will be addressed below in the remand section. Disability evaluations (ratings) are determined by evaluating the extent to which a Veteran’s service-connected disability adversely affects the Veteran’s ability to function under the ordinary conditions of daily life, including employment, by comparing the symptomatology with the criteria set forth in the Schedule for Rating Disabilities (rating schedule). 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10. Where a Veteran challenges the initial rating of a disability for which the Veteran has been granted service connection, the Board considers all evidence of severity since the effective date for the award of service connection. See Fenderson v. West, 12 Vet. App. 119 (1999). In evaluating a disability, the Board considers the current examination reports in light of the entire record to ensure that the current rating accurately reflects the severity of the condition. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. 38 C.F.R. § 4.3. 1. Lumbar and Thoracic Spine Strain The Veteran appealed the December 2015 rating decision’s assignment of an initial 10-percent rating for lumbar and thoracic spine strain. Following the Board’s previous July 2020 remand, an October 2020 rating decision granted a 20-percent rating from September 25, 2020. As this was only a partial grant of relief, the Board will consider entitlement to a higher rating. See AB v. Brown, 6. Vet. App. 35, 38 (1993). The Veteran’s thoracolumbar spine strain is rated under Diagnostic Code (DC) 5237 for lumbosacral strain, which provides that the disability should be rated under the General Rating Formula for Diseases and Injuries of the Spine (General Rating Formula). 38 C.F.R. § 4.71a. Under the General Rating Formula, a 20-percent rating is warranted where forward flexion of the thoracolumbar spine is greater than 30 degrees but not greater than 60 degrees; or, the combined range of motion of the thoracolumbar spine is not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40-percent rating is warranted where there is forward flexion of the thoracolumbar spine limited to 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. A 50-percent rating is warranted where there is unfavorable ankylosis of the entire thoracolumbar spine. A 100-percent rating, which is the highest available, is warranted if there is unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a. For VA compensation purposes, normal forward flexion of the thoracolumbar spine is 0 to 90 degrees, normal extension is 0 to 30 degrees, normal left and right lateral flexion are 0 to 30 degrees, and normal left and right lateral rotation are 0 to 30 degrees. General Rating Formula, Note (2). For VA compensation purposes, unfavorable ankylosis is a condition in which the entire thoracolumbar spine or the entire spine is fixed in flexion or extension, and the ankylosis results in one of the following: difficulty walking because of limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. General Rating Formula, Note (5). The Board now considers an initial rating higher than 10 percent from the effective date of July 25, 2015, and a rating higher than 20 percent from September 25, 2020. Turning to the evidence, a VA examination was provided on May 5, 2015. Range of motion testing found flexion to 90 degrees with pain beginning at 80 degrees, extension to 30 degrees with pain beginning at 25 degrees, right and left lateral flexion to 30 degrees without pain, and right and left lateral rotation to 30 degrees without pain. Upon repetitive use there was no additional lost motion. Guarding and/or muscle spasm were present but did not result in abnormal gait or spinal contour. The Veteran reported that he did not have flare-ups. Physical therapy notes on October 5, 2017, and November 8, 2017, found lumbar flexion to “25% limit,” extension “no limits, no pain,” and flexion and rotation to “25% limit.” Vista records uploaded to the record as directed by the Board’s previous July 2020 decision show treatment notes on November 13, 2018, December 7, 2018, and March 7, 2019, that found lumbar flexion “very restricted” and the other thoracolumbar spine movements “slightly restricted.” The Veteran expressed difficulty with activities of daily living requiring bending or lifting, leading the clinicians to find that he was “very restricted.” Another VA examination was provided on September 14, 2019. The Veteran’s symptoms included dull pain in the lower back, worse during flare-ups caused by exertion and movement. The Veteran reported inability to lift heavy objects. Initial range of motion testing found flexion to 90 degrees without pain, and all other motions to 25 degrees with pain. The examiner estimated that during flare-ups or with repeated use over time the Veteran would be limited to 75 degrees of flexion and 15 degrees in all other motions. The Board’s July 2020 decision found this estimate inadequate, however, to the extent that the examiner did not review the Veteran’s entire file in forming his opinion and therefore may not have accounted for the full extent of loss during flare-ups and with repeated use over time. The record contains treatment notes in the first half of 2020 showing continuing treatment sought for the spine. Following the Board’s prior July 2020 decision, a new VA examination was provided on September 25, 2020, and it was based on review of the Veteran’s file. Initial range of motion testing found flexion to 90 degrees, extension to 5 degrees, and all other motions to 30 degrees. The examiner estimated that during flare-ups or with repeated use over time, range of motion would be flexion to 45 degrees, extension to 5 degrees, and all other motions to 15 degrees. No guarding or muscle spasms were found. Additional factors contributing to disability included interference with standing and sitting, and disturbance of locomotion. The examiner stated that the standing and walking would be a problem at work but the Veteran otherwise could perform other duties. Based on all the evidence, the Board finds that the 20-percent rating is warranted from September 14, 2019. The September 25, 2020 VA examination, which was ordered to address the September 14, 2019 VA examination’s inadequate failure to consider the Veteran’s file, found that the Veteran’s forward flexion during flare-ups or with repeated use of time would be limited to 45 degrees. Resolving any reasonable doubt in the Veteran’s favor, the Board finds that this estimate, which was based on review of all of the Veteran’s file including his medical records, is probative of the severity of his condition at the time of the September 14, 2019 examination, and therefore finds that a 20-percent rating may be awarded from that date. 38 U.S.C. § 5107(b); 38 C.F.R. § 4.3. The Board further finds, however, that a rating higher than 10 percent before September 14, 2019, is not warranted, and a rating higher than 20 percent from September 14, 2019, is not warranted. For the period before September 14, 2019, the Board does not find the evidence sufficient to show forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees, or combined range of motion not greater than 120 degrees, or muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour. At the May 2015 VA examination, the Veteran’s forward flexion was 80 degrees, and total range of motion of all the movements was 225 degrees. The remainder of the record, while showing that the Veteran sought treatment for his spine condition, does not contain information sufficient for rating purposes. The Board notes the physical therapy notes from 2017 that found “25% limit” in flexion and lateral flexion and lateral rotation, which are not precise ranges of motion and do not appear to have been measured with a goniometer, which is indispensable in examinations sufficient for VA rating purposes. 38 C.F.R. § 4.46. Even taking these estimations as precise, however, the findings would work out to forward flexion of 67 degrees and a total range of motion of 187 degrees (calculated by applying these percentages to the normal ranges of motion for VA rating purposes), which are still not sufficient to portray a disability picture approximating the criteria for a rating higher than 10 percent. Finally, only the May 2015 VA examination found muscle spasms and/or guarding present, but it was noted not to result in an abnormal gait or spinal contour. 38 C.F.R. § 4.71a, DC 5237, General Rating Formula. For the period after September 14, 2019, a rating higher than 20 percent requires evidence of forward flexion of the thoracolumbar spine 30 degrees or less, or favorable ankylosis of the entire thoracolumbar spine. Here, the evidence shows the Veteran’s forward flexion, accounting for flare-ups and repeated use over time, would be to 45 degrees, and there is no evidence of ankylosis of the thoracolumbar spine. Id. Accordingly, an initial rating higher than 10 percent before September 25, 2020, and a rating higher than 20 percent from September 14, 2019, must be denied. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.46, 4.71a, DC 5237. 2. Bilateral Knees The Veteran appeals the initial rating of 10 percent for his bilateral knee patellofemoral pain syndrome. The Veteran’s knee disabilities are rated under DC 5260, for limitation of the flexion of the leg. 38 C.F.R. § 4.71a. Under DC 5260, a 10-percent rating is warranted where flexion is limited to 45 degrees; a 20-percent rating is warranted where flexion is limited to 30 degrees; and, a 30-percent rating, the highest rating available under this DC, is warranted where flexion is limited to 15 degrees. Id. An additional rating for knee disabilities may be available under DC 5261, for limitation of extension of the leg. Under DC 5261, a 10-percent rating is warranted where extension is limited to 10 degrees; a 20 percent-rating is warranted where extension is limited to 15 degrees; a 30-percent rating is warranted where extension is limited to 20 degrees; a 40-percent rating is warranted where extension is limited to 30 degrees; and, a 50-percent rating, the highest rating available under this DC, is warranted where extension is limited to 50 degrees. 38 C.F.R. § 4.71a. Alternatively, under DC 5258, a single rating of 20 percent rating is available where there is cartilage, semilunar, dislocated, with frequent episodes of “locking,” pain, and effusion into the joint. 38 C.F.R. § 4.71a. In addition to a rating based upon limitation of motion of the knee, a rating is available for instability in the knee. VAOPGCPREC 23-97 & 9-98; Lyles v. Shulkin, 29 Vet. App. 107 (2017). Under DC 5257, where there is recurrent subluxation or lateral instability, a 10-percent rating is warranted where slight; a 20-percent rating warranted where moderate; and, a 30-percent rating, the highest schedular rating, where severe. 38 C.F.R. § 4.71a. Turning to the evidence from the effective date of July 25, 2015, a VA examination was provided on May 5, 2015. Range of motion testing found flexion of both legs to 140 degrees, and extension of both legs to the full 0 degrees. There was no additional lost motion with repetitive motion. The Veteran reported daily flare-ups, rated 4 or 5 out of 10 on the pain scale, that lasted up to the entire day. The examiner found no other additional factors contributing to disability. Stability testing was normal bilaterally, and there was no history of recurrent lateral instability, history of recurrent subluxation, or history of recurrent effusion. There was no meniscal condition of either knee. The Veteran reported that sometimes it hurt to walk and sometimes his knees locked up. Another VA examination was provided on September 14, 2019. The Veteran’s symptoms included dull pain around the knee joints, worse on the right. The Veteran reported flare-ups upon movement and exertion that caused worse pain. Initial range of motion testing found bilateral flexion to 90 degrees and extension to 0 degrees. Both patella were painful at a moderate severity. The Veteran reported difficulty walking for long periods, and the examiner found the Veteran would be limited in any job requiring walking. Stability testing was normal bilaterally, and there was no history of recurrent lateral instability, history of recurrent subluxation, or history of recurrent effusion. There was no meniscal condition of either knee. Range of motion during flare-ups and with repeated use over time were estimated to be flexion to 70 degrees bilaterally and extension to 0 degrees bilaterally, though the Board’s prior July 2020 decision found the estimates inadequate to the extent the examiner did not review the Veteran’s entire file in forming his opinion and therefore may not have accounted for the full extent of loss during flare-ups and with repeated use over time. Treatment records from February 2020, show the Veteran had knee pain with standing and in motion. The Veteran had a sensation of weakness associated with knee pain but denied any falls. There was no edema found. The clinician noted the Veteran had a limited ability to squat. In March 2020, the Veteran rated his current knee pain at 2 out of 10, which worsened to 8 or 9 out of 10, particularly with stairs and long periods of standing. There was no locking. Following the Board’s prior July 2020 decision, a new VA examination was provided on September 25, 2020, with review of the Veteran’s file. The Veteran still had pain in both knees, without swelling. The Veteran did not report flare-ups. Range-of-motion testing found right-knee flexion to 140 degrees and left-knee flexion to 120 degrees, with extension to 0 degrees bilaterally. There was no additional lost motion with repeated use over time or during flare-ups. Additional factors of disability included pain with sitting and even worse pain standing or walking around. Instability testing was normal bilaterally, and there was no history of recurrent lateral instability, history of recurrent subluxation, or history of recurrent effusion. No meniscal condition was present. Based on all the evidence of record, the Board finds that ratings higher than 10 percent unfortunately have not been established. Regarding limitation of motion, the evidence of record does not show that either leg has been limited to 30 degrees of flexion, even accounting for repeated use over time and any reported flareups, and such evidence is required to establish a higher rating under DC 5260. An additional compensable rating under DC 5261 for limitation of extension is not warranted because there is no evidence, even accounting for repeated use over time and any reported flareups, sufficient to establish that extension in either leg is limited to 10 degrees. 38 C.F.R. § 4.71a, DCs 5260, 5261. Regarding a rating under DC 5258, though the Veteran reported in May 2015 that his knees locked up, none of the evidence establishes that the Veteran has dislocated semilunar cartilage or frequent episodes effusion into the joint in either leg. Rather, all of the evidence has found that there is no condition of the menisci and no effusion. 38 C.F.R. § 4.71a, DC 5258. Finally, a rating is not available under DC 5257, as there is not sufficient evidence of recurrent lateral instability or recurrent subluxation. 38 C.F.R. § 4.71a, DC 5257. The Board acknowledges the multiple reports that the Veteran has pain while standing, walking, and sitting. However, the regulations provide that where the limitation of motion is not severe enough to warrant a compensable rating under the applicable rating criteria, the minimum rating for limitation of motion should be assigned. See Burton v. Shinseki, 25 Vet. App. 1, 5 (2011) (interpreting 38 C.F.R. § 4.59); 38 C.F.R. § 4.71a, DC 5260, 5261. For a knee disability, the minimum rating for limitation of motion is 10 percent, which is the rating that has been assigned. Id. An initial rating higher than 10 percent for bilateral patellofemoral pain syndrome is denied. 38 U.S.C. § 1155; 38 C.F.R. § 4.71a, DCs 5257, 5258, 5260, 5261. B. Total Disability Rating Due to Individual Unemployability Entitlement to a total disability rating due to individual unemployability (TDIU) is part and parcel of a claim for an increased rating where the record reasonably raises the issue of unemployability due to service-connected disabilities. Rice v. Shinseki, 22 Vet. App. 447, 448, 449 (2009). Here, the Veteran has contended, in connection with an appeal of a rating decision granting a TDIU from November 6, 2017, that his service-connected disabilities rendered him unemployable back to July 25, 2015, the effective date of his service-connected disabilities on appeal in the present matter. Therefore, entitlement to a TDIU before November 6, 2017, is raised by the record and will be adjudicated now. Id. A TDIU may be assigned if the schedular rating is less than total, when the disabled person is, in the judgment of the rating agency, unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities. 38 C.F.R. § 4.16(a). To be considered for assignment of a schedular TDIU the Veteran’s service-connected disabilities must meet the following criteria: (1) if there is only one such disability, this disability shall be ratable at 60 percent or more; or (2) if there are two or more such disabilities, there shall be at least one disability ratable at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent or more. Id. The Veteran’s service-connected disabilities include PTSD rated at 70 percent from July 25, 2015; bilateral shoulder strain each rated at 10 percent from July 25, 2015; lumbar and thoracic spine strain rated at 10 percent from July 25, 2015; cervical musculoskeletal strain rated at 10 percent from July 25, 2015; bilateral hip musculoskeletal strain each rated at 10 percent from July 25, 2015; bilateral knee patellofemoral syndrome each rated at 10 percent from July 25, 2015; bilateral ankle strain each currently rated at 10 percent from July 25, 2015; bilateral metatarsalgia rated at 10 percent from July 25, 2015; tinnitus rated at 10 percent from July 25, 2015; and, bilateral dry eye syndrome rated noncompensable from July 25, 2015. Thus, the first criterion is met from July 25, 2015, and therefore the Board will consider whether the Veteran has been unemployable due to his service-connected disabilities at any time during the period. A Veteran is unemployable if he or she is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities. 38 C.F.R. § 4.16(a). A substantially gainful occupation is one earning more than marginal income (outside of a protected environment), as determined by the U.S. Department of Commerce as the poverty threshold for one person. Ray v. Wilkie, 31 Vet. App. 58, 72–73 (2019). In evaluating a veteran’s ability to secure and follow a substantially gainful occupation, consideration may be given to his or her level of education, skills and training, and previous work experience, but not to age or impairment caused by non-service-connected disabilities. Id.; 38 C.F.R. §§ 3.341, 4.16, 4.19. The sole fact that a claimant is unemployed or has difficulty obtaining employment is not enough. The question is whether the Veteran has the physical and mental ability to perform the types of activities required by the occupation at issue, not whether the Veteran can find employment. Id.; 38 C.F.R. § 4.16(a). The evidence reflects that the Veteran has not had a job since separation from service in July 2015. He has a four-year high school education. His military occupational specialty was engineer equipment electrical systems technician. As discussed above, the evidence reflects that during the period of July 25, 2015, until November 6, 2017, the Veteran’s thoracolumbar spine and bilateral knee disabilities affected his ability to walk, stand, lift, bend, and squat. Regarding the Veteran’s service-connected PTSD, VA has previously found that since July 25, 2015, the Veteran’s PTSD created occupational and social impairment with deficiencies in most areas, such as work, including symptoms of unprovoked irritability with periods of violence, suspiciousness, suicidal ideation, near-continuous depression and panic affecting the ability to function independently, appropriately and effectively, panic attacks more than once a week, disturbances of motivation and mood, retention of only highly learned material, impaired impulse control, chronic sleep impairment, forgetting to complete tasks, difficulty adapting to stressful circumstances and to work, impairment of short-term and long-term memory, flattened affect, difficulty establishing and maintaining effective work and social relationships. Such symptoms and more were found in a May 2015 VA examination. Resolving any reasonable doubt in the Veteran’s favor, the Board finds that the Veteran’s combined service-connected disabilities rendered him unable to secure and maintain substantially gainful employment from July 25, 2015. The Veteran’s physical impairments would impair his ability to perform the physical requirements of a job relating to the area of his training and experience (engineer equipment electrical systems technician or any other physical-labor job), and his psychiatric disabilities have been found to impair his ability to handle the cognitive and social requirements of work or worklike settings. 38 C.F.R. §§ 4.3, 4.15, 4.16. As July 25, 2015, is the effective date of service connection for all the underlying disabilities for consideration of entitlement to a TDIU, this date is the earliest date of entitlement permitted under the law. 38 C.F.R. § 3.400. Accordingly, a TDIU is granted from July 25, 2015. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.340, 4.3, 4.15, 4.16. REASONS FOR REMAND C. Initial Ratings for Bilateral Ankle Strain A September 14, 2019 VA examination regarding the Veteran’s ankle disabilities estimated that during flare-ups of the Veteran’s ankle disabilities, dorsiflexion would be limited to 10 degrees bilaterally, and plantarflexion would be limited to 25 degrees and 30 degrees in the right and left ankles, respectively. The Board’s prior July 2020 decision found this examination inadequate to the extent the examiner indicated he had not reviewed the Veteran’s file and therefore may not have accounted for the full impact of the Veteran’s ankle flare-ups. Accordingly, the July 2020 Board decision directed for a new examination, which was provided in September 2020. Though the Veteran stated at the examination that he did have flare-ups, the September 2020 VA examiner estimated that the Veteran would have full range of motion in both ankles during flare-ups. In light of the inconsistency between this finding and the Veteran’s statement that he continued to have flare-ups—flare-ups that the September 2019 VA examiner estimated would result in additional limitation of motion—the Board finds that remand is required to clarify why the Veteran’s flare-ups were estimated not to result in additional lost motion. See Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). The matters are REMANDED for the following action: 1. Associate with the Veteran’s claims file any VA treatment records not already of record. 2. Schedule the Veteran for an examination regarding the current severity of his bilateral ankle strain. If possible, schedule the examination with the examiner who administered the September 2020 examination or the examiner who administered the September 2019 examination. In addition to providing a full description of the current severity of the disability, the examiner should also interview the Veteran regarding the severity, frequency, and duration of flare-ups and the degree of functional loss during flare-ups. If it is not possible to provide a specific measurement based on direct observation, the examiner should provide an estimate, if at all possible, of the additional impairment due to flare-ups based on the Veteran’s statements and the other evidence of record. The examiner must specifically discuss the September 2019 examiner’s estimates of range of motion during flare-ups and with repeated use over time. The examiner should provide an explanation for any change from the September 2019 examination in the estimate of range of motion during flare-ups and with repeated use over time. (Continued on the next page)   3. After the above development and any other development deemed necessary is completed, readjudicate the Veteran’s claims. K. Parakkal Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. Davis, Associate Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.